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1 <br /> w <br /> FGL ENVIRONMENTAL CHAIN-OF-CUSTODY RECORD LAB PROJECT <br /> (See Reverse for Instructions) NO. <br /> 'ROJECT NAME C-Kayvc,A L�LW, SAMPLERS b2v'< SPIAL ka.r SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> �OSz/ (PRI DESCRIPTION CODES A Ground Water F. Oil <br /> 'ROJECT NUMBER A. 40-m1 VOA Vial B. Surface water G. waste 1. Standard <br /> (SIGN) B. Glass Liler E. Brass Tube C. Leachate H. Blank/Spike 2. 5 Day <br /> RECORDER l9)C ZSS'30Sy C. Plastic 50Bm1 F.O'1"`', D. Rinseale I. Omer 3. 60 Hour <br /> (SIGN) D. Plazlb Liter I�yy51 E. Soil/Semmens 4. Other__ <br /> NUMBER OF ANALYSIS REQUESTED LABORATORY USE ONLY <br /> CONTAINERS O <br /> AND 1 <br /> �— 3g PRESERVATION : ) I� $ p a <br /> F N8 $ 'y- I N po i S a '`Y SAMPLE <br /> c3_ 3 €g , E.11 uu z NOTES ASSIGNED CONDITION <br /> E ° BOTTLE UPON <br /> DATE TIME 5 PLE ID '� LL q NUMBERS RECEIPT NOTES <br /> T D <br /> I Ter >( <br /> L.aC STI. <br /> t, <br /> J{" <br /> NOTES I MISCELLANEOUS He .S Bd,b . (Signature) Received By: 'gnature) Do Time <br /> Me 4vc . Q�y �� s/79 /530 <br /> R;�uis By: (Signature) ceiv (S' sure) at Time <br /> D 1 j�e, r9� �r � c� <br /> Relinquls ed By: (Signature) Received By: (Signature) Date Time <br /> Method of Shipment - Description of Other Chains-Of-Custody Dispatched By: (Signature) Time Received for lab By: (Signature) Date Time <br /> Transport Container Transported with this <br /> - Chain (by Serial No.) <br /> Ir1�gy 3�.1�PM <br /> Send Lab Results to (Name): (Check Office Below) V Is Requested: Yes ❑ No ❑ <br /> ❑ SANTA PAULA FT STOCKTON ❑VISALIA <br /> TEL (805) 659-0910 TEL (209) 942-0181 TEL (209) 734-9473 <br /> FAX (805)525-4172 FAX (294) 942-0423 FAX (209) 738-6273 <br /> FGL ENVIRONNIENTAL LABORATORY• 2500 STAGECOACH ROAD • STOCKTON, CA 95215 • TEL.(209) 942-0181 • FAX (209) 942-0423 <br /> WHII'I!:hod Capf 1'IA IOW:P","C"' PINK:I Nnininy Corr <br />